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Cognitive and Behavioral Practice 17 (2010) 343–347

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SPECIAL SERIES
Spiritual and Religious Issues in Behavior Change
Guest Editors: David H. Rosmarin, Bowling Green State University
Harold B. Robb III, Pacific Institute for RET

Introduction
David H. Rosmarin and Kenneth I. Pargament, Bowling Green State University
Harold B. Robb III, Pacific Institute for RET

Spiritual and religious beliefs and practices are commonplace in the general population of North America today. In recognition of this
fact, research on the interplay of spirituality, religion, and psychological variables increased substantially over the past 3 decades; a
recent PsycInfo search identified over 28,000 scientific contributions to this area. However, the relevance of spirituality and religion to
clinical practice remains poorly understood. As a result, many practitioners of empirically supported treatments may be reticent to
address spirituality and religion in the course of their work. The intent of this special series is to help demystify this topic with the hope of
increasing dissemination of spiritually sensitive, empirically supported treatments. The authors in this series cast some light on this
understudied topic by highlighting several salient spiritual and religious issues in behavior change. Moreover, based on case material,
the authors illustrate how to assess for and address both adaptive and maladaptive utilizations of spirituality and religion in the
practice of cognitive behavior therapy. This introductory paper presents a rationale for why it is important to address this topic, and
provides an overview of recent research developments in the creation of spiritually integrated psychosocial treatments.

R ECENT findings from surveys conducted with nation-

ally representative samples in the United States
indicate that spiritual and religious beliefs and practices
are highly prevalent in the general population. Specifi-
cally, 93% of Americans report a belief in God or a higher
power, 76% report believing that the Bible is the actual or
inspired word of God (Gallup Poll, May 8–11, 2008), 59%
report believing that religion can answer “all or most” of
today's problems, and more than 50% indicate that
religion is very important to them in their lives (Gallup Poll,
May 10–13, 2007). Accordingly, it appears that the vast
majority of individuals seeking psychological treatments
in North America profess some form of spiritual or
religious belief (Robb, 2001; Rose, Westefeld, & Ansley,
2001). For practitioners of empirically supported psycho-
logical treatments, these facts raise some important
questions. For example, how are spiritual and religious
factors relevant to symptom presentation and treatment
outcome? Which specific factors are most salient, and how
can we identify, quantify, and address them? Can and
should client spirituality be integrated into treatment? If
so, what are the ethical issues that this raises and how
1077-7229/10/343–347$1.00/0
© 2010 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
should these be dealt with? Moreover, when should this be
facilitated, how should this be accomplished, and how
might this impact treatment efficacy? The papers in this
special series provide empirically based answers to these
and other questions relevant to this topic area. Collec-
tively, they offer rich, clinically relevant, and empirically
informed recommendations for how to address some of
the many spiritual and religious issues that arise in the
practice of cognitive-behavioral therapy. By way of
introduction to these contributions, the present paper
will attempt to illustrate why it is important to address
spiritual and religious issues in behavior change. Further-
more, an overview of recent advances in the development
of spiritually integrated treatments and an Appendix
containing suggestions for further reading is provided.
Why Address Spirituality and Religion?
Clinical and counseling psychologists tend to demon-
strate markedly lower levels of religiousness than the
population at large. In one study conducted with a
random sampling of members from Division 12 (Clinical
Psychology) of the American Psychological Association
(APA), Shafranske and Malony (1990) found that less
than 30% of respondents endorsed belief in a “personal
God of transcendental existence,” and 58% reported very
limited or no involvement or identification with religion,
or disdain for religion. In a more recent study with a
 Author's personal copy
344 Rosmarin et al.
random sampling of all APA members, almost half (48%)
of respondents described religion as unimportant in their
lives (Delaney, Miller, & Bisonó, 2007). By virtue of their
own stance toward religion and spirituality, many practi-
tioners may not be sensitive to the religiousness and
spirituality of their clients, and the need to address
spiritual and religious issues in behavior change. More
fundamentally, though, there are deeply seated assump-
tions within the field of mental health that spirituality and
religion are generally unimportant, largely unrelated to
human psychological functioning, and at most, a side
issue in psychotherapy (Pargament, 2007). These assump-
tions appear to be unfounded, however. The past three
decades of psychological research on religion and
spirituality have yielded substantial evidence to suggest
that spirituality and religiousness are indeed salient to
psychological functioning. Furthermore, spiritual and
religious factors are at times inextricable from clients'
presenting symptoms.
Perhaps the best researched construct in this area
involves the utilization of religious resources during
times of stress in a process known as religious coping
(Pargament, 1997). Religious coping is highly prevalent.
After the September 11, 2001, terrorist attacks, for
example, 90% of a sample drawn from across the United
States reported turning to religion in some way (Schuster
et al., 2001). A number of studies show that religious
coping is predictive of lower rates of depressive symptoms,
anxiety, and increased levels of self-esteem and life
satisfaction (see Harrison, Koenig, Hays, Eme-Akwari, &
Pargament, 2001, for a review). In addition to religious
coping, a rich literature ties simple behavioral markers of
spirituality and religion such as prayer, meditation, and
Bible study to decreased depression (Smith, McCullough
& Poll, 2003), anxiety (Koenig, Ford, George, Blazer, &
Meador, 1993), and reductions in the consequences of
stressful life events (Williams, Larson, Buckler, Heckmann,
& Pyle, 1991), as well as higher levels of life satisfaction (see
Koenig, McCullough, & Larson, 2001, for a review). Other
studies link cognitive facets of spirituality such as religious
beliefs to a lower incidence of depression (e.g., Koenig,
George, & Peterson, 1998) and anxiety (Rosmarin,
Krumrei, & Andersson, 2009).
Not all utilizations of spirituality and religion appear
to be psychologically beneficial, however. Recent re-
search on the topic of spiritual struggle suggests that
some facets of faith can also be a source of distress.
Spiritual struggle, which is sometimes referred to as
negative religious coping, involves strain and tension
relating to spiritual matters. Three primary types of
struggle have been identified (Exline & Rose, 2005;
Pargament, Murray-Swank, Magyar, & Ano, 2005): (a)
interpersonal spiritual struggle, which involves conflict
with others in a spiritual context, such as disagreements
with fellow congregants, or a falling out with clergy; (b)
intrapersonal spiritual struggle, which involves existential
crises resulting from questions/doubts about spiritual and
religious issues; and (c) divine spiritual struggle, which
involves emotional tension in one's relationship with God
(e.g., feeling anger towards God, feeling abandoned by
God). While less common in occurrence than positive
religious coping (McConnell, Pargament, Ellison, &
Flannelly, 2006), spiritual struggle is tied to poor recovery
from physical illness (Fitchett, Rybarczyk, DeMarco, &
Nicholas, 1999), declines in health and illness-related
mortality (Pargament, Koenig, Tarakeshwar, & Hahn,
2004), and psychological difficulties (Ano & Vascon-
celles, 2005), and therefore presents a significant risk
factor for religious individuals. The relationship of
spiritual struggle to well-being underscores the impor-
tance of assessing for potentially deleterious spiritual and
religious factors across cognitive (e.g., beliefs that one is
being punished by God), behavioral (e.g., arguing with
God), and/or emotional (e.g., feelings of anger towards
God) domains in the course of treatment (Exline, Yali, &
Sanderson, 2000).
Thus, the extant literature has clearly demonstrated
that many aspects of spirituality and religion are salient
predictors of psychological functioning. More specifically,
spirituality and religiousness can be utilized in positive or
negative ways, which divergently relate to mental health
and distress. Based on these observations, some have
proposed that spirituality/religion neither causes nor
ameliorates symptoms of mental illness in and of itself
(Ellis, 2000). In this vein, spirituality and religion are no
different from other human contexts, such as culture.
However, the domains of spirituality and religion appear
to exert a more potent and extensive influence than many
other areas of human life. This influence is not limited to
human affect and behavior; it is widely apparent in large-
scale social efforts, including war and peace (McCullough
& Willoughby, 2009). While it remains unclear why,
exactly, religion and spirituality have such a powerful
impact on humanity, it has been suggested that sanctifi-
cation plays a key role. Sanctification is the process by
which aspects of life are perceived as having Divine or
sacred character and significance (Pargament, 2007).
While virtually any aspect of life (e.g., values, beliefs,
objects, people) can be sanctified, that which is perceived
to be sacred exerts a robust influence on emotions and
behaviors, including increasing investments of time and
effort with sacred matters, taking on responsibility and
risk to preserve and protect that which is sacred, and the
elicitation of both positive and negative emotions with a
strong valence (see Pargament & Mahoney, 2005, for a
review). Thus, while perhaps not intrinsically connected
to psychological functioning, the use of spirituality and
religiousness in a positive and adaptive manner may be
 Author's personal copy
Introduction: Spiritual and Religious Issues
particularly helpful to individuals in times of psycho-
logical distress. Conversely, as described throughout this
special series, spirituality and religiousness can exert a
profound influence on how psychopathology manifests.
Given the widespread significance of religion and
spirituality to members of our society, and evidence
suggesting that these factors have an impact on psycho-
logical functioning, it is necessary to provide a clinically
useful analysis of how to deal with spiritual and religious
issues in behavior change.
Integrating Spirituality Into Treatment
Unfortunately, the “religion gap” between psycholo-
gists and general public compromises our field's ability
to disseminate treatments in the general population
(Delaney et al., 2007). Recently, only 13% of training
directors in clinical psychology graduate programs in
North America reported that their curriculum offered a
course on religion or spirituality (Schulte, Skinner, &
Claiborn, 2002). As a result, the majority of clinicians lack
training on how to grapple with spiritual and religious
issues in treatment. Furthermore, some may be concerned
that approaching this subject oversteps professional
bounds (Pargament, 2007). This is unfortunate, as there
is evidence to suggest that many clients would appreciate a
spiritually sensitive approach to treatment.
It has been established that conventional psychological
services are underutilized by religious populations as
religious individuals tend to prefer spiritually integrated
care (Puchalski, Larson, & Lu 2001). However, prefer-
ence for spiritually integrated treatment does not appear
to be limited to cloistered religious communities. A recent
survey of over 31,000 adults by the National Center for
Complementary and Alternative Medicine indicated that
43% of respondents prayed for their own health, 25%
recruited others to pray for them, and 10% joined a
prayer group for their health (U.S. Department of Health
and Human Services, 2005). In another national study,
45% of medical patients stated that too little attention was
paid to spiritual and religious concerns and 48%
indicated that they would like their physicians to pray
with them (Post, Puchalski, & Larson, 2000). While not
much research in this area has been conducted with
regards to psychotherapy, it has been noted that,
historically, North Americans are more likely to seek
help from clergy and religious communities than mental
health providers when experiencing psychological pro-
blems (Norris, Kaniasty, & Scheer, 1990). Additionally, one
large-scale study involving six mental health facilities found
that 55% of psychotherapy clients would like to talk about
spiritual and religious issues in the course of treatment
(Rose et al., 2001). Addressing spirituality and religion may
therefore be an important step towards the dissemination
of cognitive behavior therapy (CBT). It is not inconceiv-
345
able that one of the reasons for the recent popularization
of third-wave CBT, including mindfulness-based treat-
ments and Acceptance and Commitment Therapy
(ACT), is the willingness of proponents to link treatment
to spirituality and transcendence (e.g., Hayes, 2002).
In recognition of the widespread general interest in
spirituality and the need to provide religious communities
with culturally appropriate care, numerous spiritually
integrated interventions have been created in recent
years. Spiritually integrated treatments (SITs) are psycho-
social interventions that draw on spiritual resources and
address spiritual concerns (Pargament, 2007). Much like
conventional treatments, SITs target various presenting
problems, including addictions (Margolin et al., 2007),
sexual abuse (Murray-Swank & Pargament, 2005), social
anxiety (McCorkle, Bohn, Hughes, & Kim, 2005), physical
and psychological well-being among cancer patients
(Cole, 2005), and migraines (Wachholtz & Pargament,
2008). SITs have been integrated with several modalities
of psychotherapy (Worthington & Sandage, 2001).
Perhaps most significant for practitioners of empirically
supported treatments, several attempts to integrate
spirituality and religion into cognitive behavioral and
rational-emotive behavioral therapy have been successful
(e.g., Johnson & Ridley, 1992; Johnson, DeVries, Ridley,
Pettorini, & Peterson, 1994; Pecheur & Edwards, 1984;
Propst, 1980). Spiritually integrated forms of CBT are
similar to conventional CBT except that the rationale for
treatment is presented in a spiritual framework, and
religious arguments are utilized to counter maladaptive
beliefs (Nielsen, 2001; Nielsen, Johnson, & Ellis, 2001;
Robb, 1988). Furthermore, spiritual/religious practices
(e.g., gratitude exercises, blessings, prayer) can be
purposefully included in treatment as behavioral activa-
tion strategies, with the intention of increasing positive
emotions such as gratitude and hope.
While research in this area is still in its early stages, we
located 34 open and controlled clinical trials of SITs in a
recent literature search. One meta-analysis of investiga-
tions comparing religion-accommodative CBT with stan-
dard CBT for depression indicated that both treatments
were equally effective in reducing depressive symptom-
atology at 1-week follow-up (McCullough, 1999). On this
basis, it has been suggested that SITs can be offered to
clients without compromising treatment efficacy, and that
choice of SITs is a matter of availability and client
preference. However, a more recent meta-analysis may
indicate that SITs are more efficacious than other
treatments. Smith, Bartz, and Richards (2007) found an
overall effect size of 0.51 among 24 studies comparing
SITs to established treatments; that is, SITs produced a
0.51 standard deviation change in post-study measures
over and above comparison treatments. Furthermore, of
studies evaluating positive psychological variables such as
 Author's personal copy
346 Rosmarin et al.
happiness and well-being, the effect size of SITs increased
to 0.96. It should be noted, though, that the majority of
studies reviewed in this meta-analysis did not use
manualized treatments or employ fidelity checks, and
therefore these findings should be interpreted with some
caution. Nevertheless, there is evidence to suggest that
SITs are equally and perhaps more effective than non-
spiritually-integrated treatment approaches for some
presenting problems. It should also be noted that one
particularly well-designed study in this area found that
nonreligious therapists obtained somewhat better results
than religious therapists in treating clients with spiritually-
integrated CBT for depression (Propst, Ostrom, Watkins,
Dean, & Mashburn, 1992). This suggests that a lack of
religiousness on the part of a therapist is not a barrier
to the implementation of spirituality in treatment. It
therefore appears that SITs are within our capabilities to
master and are deserving of our attention.
This Series
For this special series, we collected the work of several
empirically oriented practitioners and researchers on the
subject of spiritual and religious issues in behavior change.
These papers provide readers with valuable practical
guidelines for how to (a) assess for and address salient
spiritual and religious factors in the course of treatment,
(b) determine when and how it may be appropriate to
integrate spirituality into treatment, and (c) better
understand some of the unique issues that can arise in
the practice of empirically supported treatments with
religious individuals.
First, Weisman de Mamani, Tuchman, and Duarte
(2010) examine whether religion and spirituality should
be incorporated into treatment for patients with severe
mental illness. In doing so, they provide invaluable case
examples of both adaptive and maladaptive uses of
spirituality in patients with schizophrenia from an ongoing
study evaluating a culturally informed therapy in this
population. Second, Spangler (2010) has written a rich
clinical description of how religious doctrines about the
body and religiously based eating practices can operate
within the context of eating disorders. Based on case
material, she provides a theoretical basis to inform case
formulations involving client spirituality and religion
within a CBT framework, in the treatment of eating
disorder symptoms. Next, Karekla and Constantinou
(2010) provide an overview of the processes of religious
coping and spiritual struggles in cancer patients. This
contribution further describes how to assess for these
factors and approach spiritual and religious issues within
this population using an ACT approach. Finally, Huppert
and Siev (2010) provide a theoretical framework for
differentiating religiousness from scrupulosity among
Orthodox Jews. They further illustrate how exposure
and response prevention can be used in a culturally
sensitive manner to treat obsessive-compulsive disorder in
religious individuals.
It is hoped that this special series will help practitioners
of empirically supported treatments to appreciate the
importance of spirituality and religion to clients' lives.
Moreover, it is hoped that the contributions in this series
will provide practical guidelines for practitioners who wish
to gain knowledge in this understudied area. Perhaps
most of all, it is hoped that this series will spawn the
development of greater sensitivity and skill in confronting
spiritual and religious issues in behavior change.
Appendix Suggested Readings
Nielsen, S. L., Johnson, W. B., & Ellis, A. (2001).
Counseling and psychotherapy with religious persons: A rational-
emotive behavior therapy approach. Mahway, NJ: Lawrence
Erlbaum Associates.
Pargament, K. I. (2007). Spiritually-integrated psychother-
apy: Understanding and addressing the sacred. New York:
Guilford.
Pargament, K. I. (1997). The psychology of religion and
coping: Theory, research, practice. New York: Guilford.
Robb, H.B. III (1988). How to stop driving yourself crazy
with help from Christian scriptures. New York: Albert Ellis
Institute.
Robb, H. B. III. (2002). Rational emotive behavior
therapy and religious clients. Journal of Rational-Emotive &
Cognitive-Behavior Therapy, 20(3–4), 169-200.
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Psychotherapy: Theory, Research, Practice, Training, 38, 473–478.
Address correspondence to David H. Rosmarin, McLean Hospital, 115
Mill Street, Belmont, MA , 02478; e-mail: drosmarin@mclean.harvard.edu.
Received: February 11, 2009
Accepted: February 17, 2009
Available online 12 February 2010